Neurogenic Thoracic Outlet Syndrome

Many Philadelphia 76ers fans and Husky faithful have been scratching their heads for the past 2 years since Markelle Fultz was picked #1 overall by the upstart Sixers out of the University of Washington. He had a amazingly short but dazzling career at UW declaring himself eligible for the NBA draft after running the hardwood in Montlake for only 8 months.

Recently it has been reported by Adrian Wozjnarowski that "Markelle has been diagnosed with neurogenic thoracic outlet syndrome, a physical injury," Brothers said. "TOS affects nerves between the neck and shoulder resulting in abnormal functional movement and range of motion, thus severely limiting Markelle's ability to shoot a basketball. TOS is treatable by physical therapy."

Markelle had worked on altering his shot for nearly 2 complete seasons trying to find a comfortable position that would allow him to maintain a quick release but also with accuracy. With his symptoms leading his form, as many of us athletes fall victim to at some point in our careers, it became increasingly frustrating for him and for Sixers management as he began to look increasingly like a “bust”. Now he heads to physical therapy with Judy Seto in Los Angeles as reported on twitter by Shams Charania. Judy is a great clinician and should began to help him heal.

ANATOMY AND BIOMECHANICS:

Thoracic outlet syndrome (TOS) is a condition in which there is compression of the nerves, arteries, or veins in the passageway from the lower neck to the axillary (armpit). It was first described in the early 1800s and was formally named in 1956.

There are three main types: neurogenic, venous, and arterial. 1) The neurogenic type is the most common and presents with pain, weakness, and occasionally loss of muscle at the base of the thumb (devastating for a shooter). 2) The venous type results in swelling, pain, and possibly discoloration of the upper or lower arm. 3) The arterial type results in pain, coldness, and paleness of the arm.

Take a good look at the anatomy and then move your shoulder through the shooting movement. You can easily see why in the attached videos if the rib, clavicle, or scalene are involved why this would be increasingly difficult to have consistency and accuracy.

Neuorgenic TOS may result most commonly from trauma, repetitive arm movements (shooting) or anatomical variations such as a dislocated or elevated cervical rib. This diagnosis is commonly confirmed by nerve conduction studies and medical imaging. Other conditions that can produce similar symptoms include most common rotator cuff tears and cervical disc disorders, in which the nerves of the C-Spine become compromised.

Initial treatment for the neurogenic type is with exercises to strengthen the scapular muscles and improve posture. NSAIDs such as naproxen may be recommended for inflammation or even pain. Surgery is typically done for the arterial and venous types and for the neurogenic type if it does not improve with other treatments over the course of 6-12 months.

BOTTOM LINE

Markelle Fultz attempt to find a free-throw routine

Fultz has begun the sometimes long journey to find accuracy, rhythm, and comfort once again. There have been so many batters, pitchers, quarterbacks, and golfers that I have worked with over the years where the physical impairment becomes a partner to the physiological baggage these mis-performances bring on.

This almost painful youtube video and others, basically lay out which many of us do on the golf course. Searching for a successful and pain free shot, but imagine doing this re-modeling of your lifelong trained reflex of shooting a basketball in front of coaches, teammates, and fans that are all wondering “what happened to you”. I am not doing a deep dive here on the yips or the psychology behind these changes as I believe the TOS was the injury that began the “search” for Markelle. As a former quarterback and coach I recognize how the feedback loop between the injury, brain, and outcomes can create a major impediment to full recovery and performance.

We wish him the best and that he can find the slot again and find his shot.